Junior Doctors

there are fantastic candidates who are not even getting an interview for specialist medical training

That is the trouble with our healthcare system. There is no flexibility …since junior doctors must always be paid the same, and have their wages negotiated centrally … and have nowhere else to go if the NHS lets them down

Blair’s parting gift: more doctors for fewer jobs

There comes a moment in every Prime Minister’s Questions when Tony Blair seems to wriggle off the hook. Houdini slips his chains. The greased piglet darts through the ring.

Tony’s trick involves suddenly whipping up his Labour backbenchers like a bunch of drunken Russians at a Black Sea resort. He majestically waves aside whatever charge is being put to him – systematic deception, sale of peerages, you name it – and starts a rhythmic chant about the scale of the expansion of the public sector under his premiership.

“The number of teaching assistants – UP!” he calls, and behind him the puce-faced drongoes of the Labour machine call “UP!” And on goes Blair the bingo compere: “The number of nurses – UP!”, he psalms, and “UP!” yell the Labour MPs, joyously waving their order papers. “The number of junior doctors – UP!” shouts Blair, and by now the crowd behind him is in a rowdy ecstasy, going “Up, up, up!” and jeering at the Tory benches like Millwall fans, though without the natural good manners.

As a way of seeming to be in charge in the twilight of his regime, it is really quite effective; except that we pigletologists have noticed a change in the repertoire in the past few weeks.

He no longer mentions nurses, mainly because the Government has so disastrously mismanaged the education of nurses that thousands of them are leaving university to find there are no jobs available; and now he has dried up about doctors, too.

Which is not surprising, since the final ludicrous achievement of the Blair NHS is indeed to have boosted the number of junior doctors – and by a feat of almost superhuman incompetence to have timed this sensible adjustment with a dramatic cut in the number of jobs available.

The result is chaos. It must have been a couple of weeks ago that I first got wind of the problem, when a consultant chum said he urgently needed to bend my ear about an NHS horror story; and I am afraid I didn’t give it my full attention, because the NHS is full of horror stories.

Then the letters started to come in, and the picture became clearer, and then yesterday morning a couple came up to me at the station and entreated me to do something about their son.

They told me that, for six years, they had helped him to pay for his studies, and, although they were not rich people, they had paid many thousands of pounds in the hope that he would become one of the anaesthetists this country needs so badly, and that he was now in a quandary because he had been told that there were no vacancies, and he was thinking of going to Australia.

Even by the standards of this Labour Government, the new system for recruiting junior doctors is an amazing cock-up, and a stupefying waste of money, time and talent.

The nub of it is that, this year, there are 30,000 applicants for employment as junior doctors, on the first rung of the medical ladder that leads to becoming a consultant. They are our nation’s future cardiologists, oncologists, dermatologists, and so on. They are the people, bluntly, who are going to be looking after us all.

They have already cost, on average, about £250,000 to train; and yet the Government has so catastrophically organised things that there are 30,000 of them chasing 22,000 jobs, with the result that about 8,000 will be unemployed from August.

It is not just that many good doctors will therefore be driven to other professions, or to seek a living overseas. As my consultant friend points out, there are fantastic candidates who are not even getting an interview for specialist medical training. Excellent would-be cardiologists are being forced to train as GPs, when they are ideally suited to be hospital physicians, and many good candidates – like the winner of Oxford’s most prestigious medical prize – are losing out altogether.

As with many epic bungles, this one has several causes. You can blame the sinister new internet application system, which is meant to be more rational and impersonal and less prone to the vagaries of personal contacts and networks. The trouble is that it involves a series of absurd online tests, such as “describe an ethical dilemma you have faced”, and your potential medical expertise is judged on how well you can answer this in 150 words; and given that there are now websites offering model answers, and given that candidates may not even submit their CVs, it is not surprising that one group of consultants in Birmingham was so appalled at the mismatch between what they expected, and the candidates who appeared, that they stormed out of the whole selection process.

You can blame the NHS computer system, which has crashed several times and even lost at least a thousand applications. You can certainly blame the Government, for causing a bottleneck by somehow contriving it so that two streams of graduates are competing for jobs in the same year – a looming problem to which they were alerted two years ago by my colleague Andrew Lansley.

But all this is really to ignore the fundamental reason for the disaster; and as any doctor will tell you, unless we understand the cause of the illness, the symptoms will simply recur.

I remember going to the Soviet Union in 1980, aged 16, and realising that communism was going to collapse because the shops were full of huge dusty jars of gherkins, and that was because some central planner in Soviet agriculture had decided that gherkins were a good thing to produce, even though the market was clearly saturated.

That is the trouble with our healthcare system. There is no flexibility; there are no price signals, since junior doctors must always be paid the same, and have their wages negotiated centrally, and above all they have nowhere else to go if the NHS lets them down.

There are just politicians like Blair, raving like some Stalinist commissar about “their” increase in the numbers of nurses or doctors, with no proper system to ensure a match of supply and demand.

We continue to have desperate problems in the NHS, like the pitiful plight of the injured Servicemen forced to share civilian wards; but we will never sort out those problems as long as the planning of the NHS is settled by politicians according to what gets a cheer at PMQs.

PaulD – it may be that this just another NHS story for you, but the fact is we have reached an apathy with NHS stories to the point where we just don’t care or listen anymore. A kind of “it’s only the NHS, it’s never worked” attitude. However, now more than ever we need to stop wasting money on ill thought out Labour reforms and do something radical with it. I share Boris’ concerns over this particular incident and I posted about a couple of weeks ago at http://www.pickinglosers.co.uk/blog_entry/jg/20070302/the_terminal_decline_of_the_nhs_continues

I am just waiting for someone with the guts and suggest this – any ideas Boris?

Sorry JG, I did not wish to trivialise the matter. My wife works in the HNS and one does become cynical about these things.

Last week she was tearing her hair out trying to get a wheelchair for a discharged patient with only a few days to live. He wanted to go home to die. Could she get one? Yes, the day after he passed away.

One of the excuses was “you faxed the requisition on the wrong colour paper” (think about it) – that’s after she spent a morning trying to find a fax that worked.

My only point was that Boris has that special talent for being at once serious, thought-provoking and entertaining. One or two of the ingredients are sometimes missing, though the general thrust is spot-on as ever. Perhaps it’s unfair to expect so much of him!

I think it’s an important point Boris makes about the twaddle Blair’s been peddling at PMQ’s for the last 10 years, and indeed the twaddle Gordon Brown has been passing off as his ‘budget’. It all follows the same tired script:

* Record sustained growth
* Record low interest rates
* Record low inflation
* Record investment in public services

And like Boris say’s all the Labour MP’s crow about it like it was all Gordon Browns doing, and that it is all good news.

Growth has been sustained by hiring lots of pointless public sector workers (the latest example of which are the SMoking Enforcement Officers) and by people using their houses as cash-points and borrowing on credit cards. Apparently the nation is over £1/2 billion in debt and the consumer is over £1 trillion in debt.

Interest rates have been low worldwide, in fact they were higher here than in the USA for a long time, and have consistently been higher than the Eurozone. Low interest rates have helped create huge house-price bubbles and are bad news if you’re a saver.

Low inflation has made wages stagnant at a time when they keep increasing tax. People’s earnings are going backwards under labour

As for record investment in public services, they’ve gone through years of throwing money indiscriminately at the public sector. Now that they need to start tightening their belts. In local government, they’ve changed the licensing laws and hired more licensing officers, hired an army of climate change officers and people to promote fairtrade coffee, now it’s smoking enforcement officers. All the investment has beren pointless and unnecessary. When the cuts come managers won’t want to get rid of their pet projects, they will cut services and leave your town hall full of people who sell fairtrade coffee, fine you for smoking and sit around tables plotting how to get you out of your car and save the planet.

If the NHS has been run anything like that I’m not surprised doctors and nurses are being laid off. In the local jobs paper this week they were advertising for the following:

I’m a junior doctor facing unemployment and very grateful for your article. I’m not surprised you had not heard of this crisis until two weeks ago. My impression is the government make decisions over coffee and don’t consult anyone. Then they keep everything quiet.

There are so many depressed, stressed, and tearful junior doctors. The worst is that we are so helpless.

What I miss most is my freedom. For example, I’m a Londoner, born and bred, but if the deans decide to give me a career in pathology in Scotland, I have to accept it or face unemployment. Then I’m there for ever. Goodbye home and girlfriend. Goodbye mum and dad.

I prefer the old system – at least you could try for the career option of your dreams for however long you wanted. This freedom lost is the most important thing to me. I thought we fought the Nazis in WWII for our freedom. We seem to have lost it with this government.

Hi Anon,
A succinct recap of the problem, thanks. For you to be able to put it so neatly clearly highlights the NHS’ inability to manage it.

The fact is, the NHS should be able to accurately predict it’s future requirement for doctors based on when it’s current staff will retire, and historic attrition. They have lots of experience, and should be getting this within 8-10%, not 36% overproduction.

The concept is of course simple, the devil is in the execution. It’s how Tesco seem to never go out of stock of stuff, but Sainsbury had serious stock out issues a couple of years ago. It’s a measure of competence, and, since the government effectively control both supply of, and demand for, doctors in this country, for them to mismatch in this scale is clear evidence of incomptetence.

Government incompetance is half of it. The other half is the arrogance of the deans and other senior doctors, such as Prof Alan Crockard (MMC National Programme Director) and Kevin Smith (MMC Programme Lead) who organised ‘Modernising Medical Careers’.

The government got the numbers wrong – hence the unemployment.

The MMC organisers developed a system to “make us an offer we can’t refuse”: We must accept a specified job in a specified part of the country, or we are unemployed.

Of the two, the arrogance of the senior doctors is the worst aspect because this is permanent. The government’s incompetance may only last until the next election, or until enough doctors are forced out of UK medicine.

Unfortunately, consultant arrogance is rife and the attitude responsible for the widespread ritual humiliation of junior doctors. Humiliation comes from all quarters and is not really dependent on doing anything wrong.

The stress of the job and increasing demands for productivity drive seniors into taking it out on the easiest targets – the house officers who, frankly, don’t have much of a clue anyway. Sometimes it’s fair, sometimes it’s been for events entirely out of my control. Attempts to explain are lost in the general wrath of worn-out, frustrated people.

The deans seem to turn a blind eye to bullying. There is little teaching of junior doctors on the ward. It’s mostly ritual humiliation.

This arrogance has come to a head in the way junior doctors are treated by this MMC system.

I’m an engineer. Employment for us is declining in the UK, but I manage to keep in work by not really having too much of a bag on my head about getting ‘the perfect job’

I guess you’re posting anonymously ‘cos you’re a quack & don’t want to do yourself any career damage by speaking candidly? I have few principles, but one is to quit a job where I worry about the consequences of telling the truth. There’s plent of opportunity for medics in Oz, so what are you complaing about? If the NHS are too dumb to treat you properly, stop wasting your time arguing with them, and work for people who are pleading for your services & have better surf.

– The engineering jobs market is not controlled: You are free to apply for any job you like. We cannot apply for any job we like in the UK.

– When I am given a job in the NHS, I am expected to continue with it, no matter what. If I find it’s not for me, too bad. There is no changing to another speciality.

– I am posting anonymously because telling you these simple truths would have me thrown to the wolves by the deans. They are all-powerful and a mechanism is not there to challenge any decision they make. Don’t forget, their jobs are on the line with MMC and now it is public. Self-preservation will be their first consideration.

– Why should I leave England. England is my home. I was born and bred here. My family and friends are here.

– If I go abroad, it’s a one-way ticket. MMC gives me little or no credit for experience gained abroad. Coming back would be virtually impossible.

– I’ve wanted to be a doctor all my life. I was happy with the old system because it allowed us to apply for any job we wanted every six months or so.

– Lastly, I don’t argue with people, but I believe in discussion with a view to changing things for the better. Therefore, if there is anything I’ve written which you do not agree with, please let me know so I can think about it.

Boris, I was one of the two ‘parents of a junior doctor’ who spoke to you on the station platform on Wednesday morning. Thank you for listening to us so patiently and for the article that you subsequently wrote. The arrogance and incompetence of those responsible for the MMC fiasco beggars belief. As we told you, our son has no interview and is now contemplating emigration (which he does not want to do). What a waste of this country’s investment in his 6 years of training.

Well Anon, it looks like you’re in a corner. I can’t fix it, it seems you can’t, and the NHS won’t.

Gordian Knot ring any bells?

Your choice is basically, engage with a broken process, in the knowledge that you are helping perpetuate it, or don’t, in the knowledge that if others don’t join you then you will damage your future career prospects.

Alternately, there is the Homer Simpson approach, in which you don’t complain, you just do your job in a really half arsed way. I think it’s called ‘Learned Helplessness’ (You’ll know better I guess, that sort of stuff is your area of expertise) and is rampant in public ‘enterprise’ – It’s why no-one is ever to blame, the cost inexorably rises, and quality plummets. It’s why nationalised industry inevitably results in no industry. It’s the future. Resistance is futile.

Hmm.
I think your complaint would fall on more fertile ground if you spun it up do make it look like you were more concerned about the poor value for money you were able to deliver within current structures, rather than how your career may not be going quite like you would like.

You’re in the top 5% of the population, complaints about how ill done by you are won’t attarct much sympathy. See if you can link the cause of your plight to freezing pensioners or something.

Seriously: No-one is interested in listening to other people whine. You’ll get much better results if you can present your problems, and their solutions, in a positive light.

I don’t believe in spinning anything! Maybe we should wait for the whole MMC process to finish and see what happens? Will the government match junior doctors to career slots correctly – they must get it right first time. There is no mechanism for second tries.

Personally, I don’t think any government run system will work as well as the traditional jobs market. Unfortunately, I don’t trust the deanerys to manage my career as well as I could manage it for myself. Junior doctors and their families already think they are “arrogant and incompetent”.

I don’t know what impact this will have on patients, but I would rather a happy workforce. Freedom is very important – our choice of career is one of the very few chances we have to express our freedom.

By the way, sometimes I’m tempted to join the Royal Navy: A&E, trauma, and infectious diseases are big interests of mine. I don’t imagine I’d get much freedom, but at least I’d be following a career interest that I might not be able to do under MMC. However, I would miss my London borough. I’m a real Londoner at heart.

I think the inability of central planners to anticipate a volatile market was the crux of Boz’s post, and I entirely agree. It moves responsibilty from the people who are able to take decisions, to those who aren’t, infantalising them in the process. Gordon Brown may be ‘ferociously intelligent’ but he really isn’t able to make effective decisions for all of us, and so by trying, he proves himself also to be hopelessly naive.

One of my quack mates got ticked off with the whole miserable affair & now works in Canada, and it’s impossible shutting him up about how great it is. You do have options.

In this day & age, you ignore the power of spin at your peril. 45 minutes ring any bells?

They are voicing the concerns of doctors far more effectively than the BMA! To that end, they will be more useful to you than my opinions!

Secondly, I agree spin is powerful. The ’45 minutes’ got most people supporting Tony ‘Bliar’. However, this spin (lie) is the most important reason why the Labour party could easily lose the next election.

Spin (lying) is something you would expect the ‘lower echalons’ of society to do. Responsibiliy and spin don’t mix. (And I am proud to say that one of the duties of a doctor is to tell the truth!)

I think everyone has a bit of an interest in the welfare of medics. As a high profile profession, who we pay a fair amount for, we like them to be working effectively. Like Firemen (who, oddly, my girlfriend has a near religious fervour for) we tend to view them all as fundamentally decent philanthropic types (after all, who but the most saintly would want to hang out with all those nasty ill people)and hold them in consummate regard.

Sure, reality may not quite be that sunny, and we probably project our unrealistic ideals onto you, at least you aren’t held in the entirely reasonable contempt reserved for estate agents.

Whilst I find your optimism cheering (in your comment that the ‘lower echelons’ are most likely to lie – or do you include politicians in this group?) I’m a little concerned that you suggest labour ‘could’ lose the next election. I think the word is ‘should’.

Yes – I will be marching tomorrow. And yes, you’re right – Labour definitely should lose the next election.

I apologise if our motives look like uncharitable self-interest, but nobody in power seems to be looking after us. We’re only flesh and blood too, you know.

Perhaps I should put things into context – I’ve got three degrees (including my medical qualification + several academic prizes) and I’m working towards my Member of the Royal College of Physicians final exam. I work 80 hours a week – one weekend in three, four weeks of night shifts a year. Usually I’m on call over Christmas. It’s very rare for anyone to say thank you, and now I face the real prospect of being unemployed! IF I get a career, I might not have a say for either location or type of job!

Enlightened self interest is the best basis for along term relationship of any sort. Never be ashamed of looking out for number 1, it’s not anyone elses’ job.

That said, no-one else will help you unless you can ofer them a benefit by doing so. The best benefit is to make them feel good about themselves, by appealing to their basic human decency. (the uncharitable may call this vanity)

A result of poor allocation of suitable candidates in the health system means the man in the street – who pays doctors’ wages – will suffer.

The NHS will bankrupt this country if it is allowed to continue as it is, a state-run bureaucracy, a ‘health service’ which treats disease and sickness once it is embedded. Perhaps it should start to concentrate a serious amount of time and resources on propogating real health – not just the absence of disease. Otherwise the continuing spiralling cost of drugs and ‘Western’ diseases will become inhibitively expensive.

When Cuba lost its Soviet financial and chemical ‘benefits’ as the USSR collapsed, it re-appraised its nation’s health and food production. Today Cuban birth and mortality rates are the equal of the US’s, for a tiny financial investment. They concentrate on keeping people healthy, rather than allowing them to become diseased then feeding them drugs.

As the UK will be forced to reappraise its approach to general health as the 21st century progresses, the American approach to health (the instant drug-cure – but lingering ill health) will become increasingly questioned.

Of course synthesised drugs have established their place as life-savers, but perhaps we should examine why both my financially-motivated as well as medical friends advise people to invest in medical company shares, ‘guaranteed to bring good returns in the short and long term.’

This may sound callous to doctors and their friends/relatives, but what would be wrong with letting the law of supply and demand take effect? Too many doctors: the market price falls and we employ more doctors at a lower average wage, discouraging people from entering the market. Too few doctors: the market price rises and we attract more doctors into the market. Other markets don’t need a “system” to ensure supply and demand balance. That is what price is for.

We seem to be confusing the concept of demand. The Government does not control demand, they simply filter it. When their rules mean that patients can’t be treated, they haven’t removed the demand, they have simply prevented the demand from being met. We don’t need the Government to manage the market, we need them to get out of the way so that the market can find its equilibrium price and trainee doctors can find a job at that price (or look elsewhere if they think they can do better).

Having too many doctors sounds like a nice problem to have. Why do we react to it by trying to limit the supply of doctors even when there is an oversupply, so we can maintain wages of incumbents at an artificial level? When has such an approach ever benefited anyone other than the protected oligopoly? In any other market, such action would attract the attention of the OFT. Oh, the joys of state allocation.

For all the claims that government should be able to plan this accurately, is this not a classic example of the impossibility of economic calculation under a socialist system? How many times do governments have to make apparently inexplicable mistakes before people realise it is not only or even mainly incompetence, but the system itself that is at fault.

As a junior doctor, I agree with you! I believe in the law of supply and demand. I am definitely not doing this job for the money – a lower salary is all right if it means having the job. An even lower salary is acceptable if I could have a career closer to home and in a favourite speciality.

Is that figure of 30,000 junior doctors coming on the market annually correct. If so, assuming they work for 35 years the stable number of doctors in Britain will be a bit over 1 million in a country with a working population of about 28 million?

I was one of the thousands of junior doctors marching against MMC in London today. David Cameron’s speech was excellent; it got the loudest cheers.

The best thing he said was: “There is a simple truth at the heart of this: you came into the NHS not because you wanted to get rich or famous, but because you have a vocation about curing the ill, about serving the community.” I felt proud and bit more confident when he said that.

David Cameron is definately wise to this government’s low cunning. He said we must look at the review of the reforms very carefully – they could just endorse the dreadful MMC process without advising significant change. If they do this, Mr Cameron will demand the MMC is scrapped immediately.

He also said:

– MMC is a “shambles”.
– MMC “disempowers and degrades” the profession.
– A Conservative government would treat doctors like “human beings”.

You need only look at the MMC home page to understand why it was doomed. A finer example of management NuSpeak you’d be hard pushed to find. It seems to have come from one of those computerised jargon generators which produce at random impressive-sounding but ultimately meaningless sentences from a collection of hooray words. Here goes…

Modernising Medical Careers (MMC) aims to improve patient care by delivering a modernised and focused career structure for doctors through a major reform of postgraduate medical education. It aims to develop demonstrably competent doctors who are skilled at communicating and working as effective members of a team. As training and education are central to the work of doctors and their role in delivering patient care, MMC will also bring about significant changes to career structures, providing qualified staff who are able to meet the needs of patients.

To do this, MMC has created two-year foundation schools that will, for the first time, require doctors to demonstrate their abilities and competence against set standards. There will be an opportunity to develop experience in a range of specialties. This will offer doctors the chance to gain insight into possible career options or to build a wider appreciation of medicine before embarking on specialist training.

Post-foundation, specialist/GP training will be streamlined to deliver specialists who are judgement-safe and able to deliver the care that is needed to treat patients, without compromising in any way on standards. Streamlined training will also afford further opportunities for supra specialisation that are flexible enough to allow doctors to adapt to accommodate changes in medical technology. In this way the new system under MMC aims to provide the right numbers of doctors to meet changing service needs.

Streamlined training and explicit standards of assessed competence are also essential if doctors’ careers are to accommodate the pressures of a family and modern lifestyles. MMC aims to greatly improve the opportunities for those who wish to take a break in their careers and will promote fairness and equality of opportunity at all stages of a doctors’ career.

Modernising Medical Careers is also a key enabler for other flagship programmes in the Department of Health. It is focused on the development of a flexible workforce of doctors, who are both competent at dealing with the acutely ill and who are effective at communicating with patients and colleagues alike. These skills and the absolute guarantee of standards from new methods of assessment are key to the success of modern workforce programmes like the Hospital at Night, and the Working Time Directive. Most importantly, however, MMC will deliver a modern training scheme and career structure that will allow clinical professionals to support real patient choice.

PaulD – I see what you mean. If only there was an online translation package. What was the most worrying was: “It aims to develop demonstrably competent doctors who are skilled at communicating” – what about doctors who are competent at healing the sick? Or are they just meant to persuade you to feel better about being ill and having no operation??

So how much of the blame falls on Hewitt then? I always thought she was a terrible Minister, at everything she did. When Rover went under she patronisingly stuck up for it’s incompetent managers lining their pockets claiming ‘they take risks’ as if the public don’t know what limited liability means. I cringed when they put her in charge of health.

Equally worrying is the word ‘competent’ What happened to ‘excellent’? Excellence has died with NuLab (is it too elitist?).

Next time you’re ill you will be cured by streamlined programme delivery from a flexible workforce with judgement-safe skills afforded by a flagship key enabler. Wow, I feel better already.

My wife (who works on the fringes of the NHS) believes all this is designed to put the James Robertson Justices – the autocratic consultants who run the show – in their place. Apparently there are still a good few who will not be spoken to by a nurse, an attitude out of kilter with this egalitarian age. Could someone on the wards shed more light?

Give me a break, local, and national, government departments never stop bleating on about ‘excellence’. It’s just another buzz-word.

Every time I’ve used the NHS I’ve never had a problem with it. My Mother worked in it all her life and never had any serious problems with it. The only health practitioners I’ve ever had a problem with are occupational health ones, who work according to the mindest of idiotic health and safety at work legislation. You can be signed fit to work by both a GP and a consultant then after six months of bureaucratic nonsense some foreigner can decide you’re not fit to do your job after all.

Now I just lie about my medical history on every job application form to save myself another six months of bollocks. Ironically I hear that’s exactly what the successful applicants under the MMC scheme did – either downloaded model ansers from the internet or had senior colleagues do it for them.

In the moral vacuum of New-Labour’s Britain the best thing you can do is lie and cheat.

In addition, the government are changing the NHS for the worse. For example, the years it takes to train a surgeon will be dramatically reduced. This means surgeons will be “fit for purpose” in routine operations, but if a complication develops, they will be completely out of their depth.

Give me a break, local, and national, government departments never stop bleating on about ‘excellence’. (StevenL)

Ah, but in what context? The public sector has plenty of candyfloss words about “striving for excellence”, designed to make an organisation look and feel good about itself.

But when it comes to employees, all that’s expected of them nowadays is “delivery of a programme”. This sterile attitude to work and learning starts right back in primary school and remains the principal driver all the way to the jobs market. It is how New Labour operates; people exist only to carry out orders handed down from on high by politically-influenced “strategists” who know what’s good for them and the nation.

Ask any teacher what depresses them most about their job and they’re likely to tell you how a once highly regarded vocation has been reduced to “delivering the curriculum”. For this you need “skills” and “competencies”, not understanding, imagination or resourcefulness. These have no place in the “workforce”. It seems the medical profession is turning out the same way.

Was Beethoven motivated by a requirement to deliver a quota of symphonies? Did Einstein achieve his targets in delivering a relativity programme, or Newton meet his job description criteria on defining the laws of gravity? Did Olivier deliver King Lear to ISO standards?

Did Brunel meet his engineering objectives on time and within budget? Yes, most of the time, without New Labour’s help and while smoking 40 cigars a day.

Excellence? Passion? Forget it. These are reserved words, applicable only to the council’s diversity and equality programme.

I am apolitical but I think we need a change of government. Any party in power for as long a NL has been, especially with the same leader for all that time, is going to end up in the sort mess that this one is in. It is not their fault, it would happen to anyone.

there are worse things for a potential cardiologist than training as a GP instead.general practice is where all patients come from and most present their illness and disease first.it is an under appreciated and often denigrated speciality but is of more importance and more relevance for more people than any other speciality-don’t look upon it as a last resort of place of work for rejects;many of the brightest students choose it for their careers.

Crispin: From your statement it can be concluded that it is their fault. If every government becomes stale over time, the government should leave (either by rational self assessment, that they had passed their sell by date, or by being booted out of office by an enlightened electorate)

They don’t leave because they like being in control, because they think we’re too stupid to think for ourselves, and have convinced themselves that we ‘need’ their interfering nanny bureaocracy, and because enough of the electorate fell for their lies at the last election.

Imagine you’re a person of “a certain age” and you feel dizzy, or let’s say you have rheumatism of one finger. You go to your GP and he’ll put you through lots of unrelated tests because he can tick boxes to earn him lots of money achieving government targets. You be going to hospital for blood tests for diseases you MIGHT have (but are likely to). The targets don’t necessarily encourage GPs to talk to you about your ‘presenting complaint’. Or to put it another way, they might not talk to you as much as they should because whatever you came in with wasn’t a government target! So it’s not so important is it!

A knock-on effect of this system is it encourages doctors to choose this job because of the financial reward, not because they want to help someone.

Captain
But they are addicts – addicted to power. They are human and cannot help themselves. A start might be a constitution which prevents an individual occupying one of the main offices of state for more than, say, 8 years. (They had that idea in the USA a while go.)

A start might be a constitution which prevents an individual occupying one of the main offices of state for more than, say, 8 years

I’ve thought for some time that one of the very few things we could learn from the US would be a ‘no third terms’ rule. Whether you like Thatcher or Blair or not, it can’t be denied that they’d both used up all their ideas by the end of their second term and their third was defined by political infighting which was bad for both parliament and the country.
Of course, the down side to this would be having Broon as PM now.

This is an interesting issue and it sounds like a scheme to disempower doctors.

What has been done with teachers all over the world is rather similar. You train too many and then can force them to teach in areas they wouldn’t ordinarily want to live.

This tremendous competition for jobs then means teachers haven’t the energy to worry about how much they are paid in the effort to just get employed.

Its a matter of supply and demand really with greater supply leading to diminished bargaining power.

There are actually lots of professions that people waste a lot of time being trained for with no hope of ever being employed and there is so much competition for jobs that wages are poor.

Doctors have always been rather better than others in ensuring that this doesn’t happen to them. I hope your fight is successful because of all professions doctors have the most invested in education and the most to lose.
Best of luck

I agree with you. As a junior doctor with three related degrees, I have an enormous amount to loose. I’m now too old to start a new career, and not experienced enough to do clinically related work, such as medico-legal advising.

Even my limited knowledge of the Swiss healthcare system can tell me that they have an infinitely better arrangement. The State via Cantons set what is the minimum cover. Private companies offer their policies to the patients who can top up if they desire or change provider. Providers must not abandon people when they are old or have cancer etc.

What this does is create competition, yet not anarchy.

I suspect if this was proposed in the UK the biggest complaint would be from the Unions, who would then not have a single entity to hold to ransom. Call me cynical.

Qualified medical doctor? Assuming you can get into character as an “English gentleman” (generic), you have opportunities coming out of your ears. But sadly, not in the UK. If the UK government is stupid enough to train you at vast expense to the taxpayers, and then not ensure you can find gainful employment in your profession, more fool them. Seek your fortune in the colonies, or better yet a move to more grateful country that recognises talent when it sees it.

His resignation follows his referral to the GMC by Linsay cooke, founder and coordinator of Mums4Medics. You can read this superb letter below. It is very long, but this is the first time this letter has been placed on a public website.

Remember, you read this historic letter first on Boris Johnson’s website!

General Medical Council
Regent’s Place
350 Euston Road
London NW1 3JN
26th March 2007

Dear Sirs

Re: Professor Alan Crockard, GMC no. 0174862

I write to you as a lay person who is also the co-ordinator of Mums4Medics, an ad hoc lobby of the parents and significant others of junior doctors caught up in the current crisis in post-graduate training.

Since Mums4Medics came into being I have corresponded with many families, and with doctors both senior and junior. It will be clear from what follows that I have had detailed input from doctors in the formulation of this letter. These doctors wish to remain anonymous for the moment – given the current climate of fear and uncertainly I am sure you will understand. However, should the GMC decide that Professor Crockard has a case to answer, at least one of these doctors will come forward publicly.

It is my privilege to provide them with a voice for their detailed concerns. I would not have agreed to send this letter over my name if I was not persuaded that the arguments put forward here are worthy of the GMC’s consideration.

The current crisis in post-graduate medical training is a result of Modernising Medical Careers (MMC) and the Medical Training Application Service (MTAS). In recent days numerous senior doctors have openly spoken out against these reforms, the Secretary of State for Health has been called to Parliament to explain government policy, and 12,000 junior doctors have marched through central London. There has also been considerable coverage from both broadcast and print media.

The scale of this crisis is unprecedented and due to the complexity of the problem, I am told that a solution may be difficult to reach. Statements from both the Royal College of Physicians and the Royal College of Surgeons (England) suggest that non-emergency NHS services might have to be cancelled while attempts are made to find a solution. The public are bemused, and it seems clear that this affair may lead them to question their trust in the medical profession.

Professor Alan Crockard (GMC number 0174862) is the national director of MMC and ultimately responsible for MMC and its implementation.

I respectfully ask the GMC to examine the conduct of Professor Crockard in this matter and, if it is found wanting, to consider disciplinary action.

I understand that your usual remit relates to direct patient care, but recent high profile cases have confirmed the GMC’s wider jurisdiction. I refer to the cases of Dr Andrew Wakefield and Professor Sir Roy Meadow.

In support, I wish to draw your attention to the standards expected of a registered medical practitioner as detailed in GMC publications, principally ‘Good Medical Practice’ and ‘Management for Doctors’.

The GMC’s jurisdiction in this particular matter
It seems clear that the GMC has jurisdiction over the conduct of Professor Crockard in his role as national director for MMC. Paragraph four of ‘Management for Doctors’ states:

“You remain accountable to the GMC for your decisions and actions even when a non-doctor could perform your management role”

It seems clear that the GMC expects any doctor in a managerial role to adhere to their guidance and standards. Paragraph seven of ‘Management for Doctors’ states:

“…you must make every effort to follow the guidance in this booklet, where it is your responsibility and within your power to do so …”

As national director of MMC, it would seem it was both the responsibility and within the power of Professor Crockard to follow GMC guidance.

“The extent to which you will be held accountable will inevitably depend on the circumstances: your position, the resources available to you and the nature of the problem will all play a part in evaluating the extent and nature of your accountability.”

The above statement appears to indicate that Professor Crockard can be held fully accountable for the MMC crisis due to his position and the resources available to him in this role.

The overall responsibility of Professor Crockard seems to be confirmed by paragraph fifty-three of ‘Management for Doctors’:

“You will still be responsible for the overall management of the tasks you have delegated.”

Professor Crockard’s awareness of his responsibilities
It can be argued that Professor Crockard should have been fully aware of the extent of his responsibilities. Paragraph nineteen of ‘Management for Doctors’ states:

“You should establish clearly with your employer the scope of your role and the responsibilities it involves.”

Responsibility for the choice of selection methods therefore seems ultimately to lie with Professor Crockard also. If this argument is accepted, he would be responsible for:-
• the selection and implementation of the computer based application process;
• ensuring that the selection system would work within the deadlines set, and within the various logistical constraints, for example, available consultant time for shortlisting and interviewing;
• delivering a process which would be accepted by the medical profession with regard to reliability of the outcomes, and successful integration of the old system into the new system.

It could also be argued that, given the optimism about MMC of its creators, it should have stood as a shining example of how medical selection and training should be run. Instead, the system has thus far been an abject and costly failure.

MMC and GMC guidance
In addition to the enormous burden on the NHS that MMC selection has thus far proved to be, various aspects of its design seem to fall foul of GMC guidance. ‘Management for Doctors’ lists requisite knowledge for such endeavours. Paragraph eighteen includes:

• use and application of information and information technology
• limits of what is affordable and achievable
• culture of the organisations in which you work
• principles of good employment practice and effective people management

Despite the many questions and concerns raised about the shortlisting process, Professor Crockard has continued to defend its validity. Paragraph nine of ‘Management for Doctors’ lists principles for the conduct of holders of public office, which extend to doctors in managerial positions. These include:

• Integrity
• Accountability
• Openness
• Honesty

Moreover, the final sentence from ‘Duties of a Doctor’ reads:

“You are personally accountable for your professional practice and must always be prepared to justify your decisions and actions”

I am informed that numerous legal challenges are in the process of being mounted in response to MMC selection. Preliminary reports have suggested that such legal challenges have a high chance of success. This situation has only been worsened by the frequent compromises announced in recent weeks in response to meetings of the MMC review group. It therefore seems inevitable that in the near future legal rulings will only add to the current chaos.

I am informed that this situation could have been prevented by adequate consideration of employment law when the system was designed. The managerial responsibilities of Professor Crockard are clearly stated by the GMC. Paragraph twelve of ‘Management for Doctors’ lists a number of outcomes which any doctor in any managerial position must ensure. These include:

“All decisions, working practices and the working environment are lawful, with particular regard to the law on employment…”

Such breaches of employment law can give rise to allegations of unfair discrimination. Paragraph forty-seven of ‘Management for Doctors’ relates to the fair treatment of colleagues:

“All doctors must treat their colleagues fairly. You must tackle discrimination where it arises…You should have a working knowledge of the relevant law…”

This is confirmed by paragraph forty-six of ‘Good Medical Practice’:

“You must treat your colleagues fairly and with respect. You must not bully or harass them, or unfairly discriminate against them…”

A number of stakeholders have sought to make complaints against the application processes designed by the MMC team and executed by MTAS. Due to the convoluted system, it has been difficult for affected individuals to know where to direct their complaint. Replies to complaints have, it is reported, been slow, inaccurate, unhelpful, or non-existent. Paragraph fifteen of ‘Management for Doctors’ makes the following recommendation for managers:

“You should make sure that adequate systems are in place for investigating complaints promptly, fairly and thoroughly…”

Following the highly questionable MTAS shortlisting results, a number of applicants wrote to individual deaneries to request release of data under both the Data Protection and Freedom of Information acts. Individual deaneries have replied stating that following guidance from the MMC team and the Department of Health, such information may not be released until the conclusion of the second round of applications. Many applicants believe this reply to be contrary to these acts, and have written to the information commissioner to complain. It seems possible that individual deaneries have been misinformed by the DoH/MMC team. Paragraph forty-two of ‘Management for Doctors’ states:

“provide data protection and records managers with the training and support they need to carry out their responsibilities”

It would therefore appear that this guidance might be in breach of the above GMC standards. If this policy of non-release of data originated from the MMC team, Professor Crockard must accept ultimate responsibility.

MMC and its implications for patient care
Many concerns have been expressed at all levels of the profession that the Modernising Medical Careers reforms will be detrimental to patient care. A number of reasons have been given for this.

Firstly, according to figures from MMC, there are 32,000 applicants for 23,000 posts. Inevitably this will lead to 9,000 junior doctors facing unemployment in August. The NHS is overstretched; will care not suffer without these 9,000 doctors?

Secondly, under MMC proposals, doctors will be awarded their CCT following fewer years as a trainee. Combined with the mandatory reduction in working hours following the European Working Time Directive, this can only result in CCT holders with poorer knowledge, skills and experience as compared to current newly-qualified consultants. To suggest that the widespread adoption of competency based training will overcome the reduction in training hours is just that – a suggestion. Evidence to support this claim is scarce, and certainly cannot alone justify such widespread reforms to training.

Thirdly, the MMC proposals do not allow for trainees to gain a broad experience as a junior before selecting a specialty. Many believe this is one of the great strengths of the current system. MMC training will equip doctors with a narrower field of experience as well as less experience. It will also force doctors to commit to a specialty early, thus possibly increasing the numbers of doctors in specialties for which they hold little enthusiasm. These factors are all arguably detrimental to patient care.

Many believe an erosion of standards is the inevitable consequence of MMC. Such an outcome would be against a number of standards set by the GMC.

Paragraph ten of ‘Management for Doctors’:

“All doctors have an obligation therefore to work with both medical and non-medical managers in a productive way for the benefit of patients and the public.”

Paragraph twelve lists a number of outcomes which any doctor in any managerial position must ensure. These include:

“Systems are in place to enable high quality medical services to be provided”

“Care is provided and supervised only by staff who have the appropriate skills (including communication skills), experience, training and qualifications”

“Significant risks to patients, staff and the health of the wider community are identified, assessed and addressed to minimise risk…”

‘Duties of a Doctor’ makes the following requirement under the heading ‘Provide a good standard of practice and care’:

“Work with colleagues in the ways that best serves patients’ interests”

If these arguments are accepted, it seems possible that Professor Crockard may have acted in breach of these various GMC standards.

Professor Crockard’s interaction with colleagues
There have been worrying reports that the culture of the MMC team has been one of spin, denial, silence, and deception. This has only served to increase the anger felt by the profession, and add to the worries felt by applicants to this system. Whatever the truth of these reports, Professor Crockard must, once again, take ultimate responsibility for the effects of his team’s perceived behaviour. Paragraph seventeen of ‘Management for Doctors’ expresses the need for managers to:

Sadly, Professor Crockard seems not to have listened to constructive feedback from colleagues. The British Medical Association has long been calling for changes to the MMC proposals, but these have fallen on deaf ears. The team responsible for MMC appears to many to have been making light of the crisis. The BMA’s Junior Doctors Committee has now withdrawn from the Review Body as has the Chair of the Consultants Committee. The medical profession generally now finds itself in a difficult position.

Such an approach to the real concerns of colleagues is not consistent with the standards expected by the GMC. ‘Duties of a Doctor’ lists the principles any medical practitioner must follow in their work. Under the heading ‘Be honest and open and act with integrity’ are the following statements:

“Never discriminate unfairly against patients or colleagues”

“Never abuse…the public’s trust in the profession”

It appears possible that Professor Crockard has failed to meet these standards in his role as national director of MMC.

The effects of MMC/MTAS
It is difficult not to draw the conclusion that the chaos the medical profession now finds itself in is a direct result of the poor planning, implementation, and overall management of the MMC team. As its national director, Professor Crockard must accept ultimate responsibility. The GMC publication ‘Management for Doctors’ details the requirement for appraisal of those doctors in managerial positions (paragraphs thirty-two and thirty-three):

“You should also take part in annual appraisal and revalidation, both of which should involve someone who knows about management looking at your performance as a manager”

“You should review your own performance as a manager and take part in regular audit and reviews”

The GMC may wish to examine whether Professor Crockard participated in such appraisal and review processes.

Given the scale of the disaster, it is difficult not to conclude that Professor Crockard may have been working beyond the limits of his competence. Indeed, the British Medical Association’s Junior Doctors Committee recently called for Professor Crockard to resign. I am told that surveys conducted by both RemedyUK and Professor Brown (Addenbrooke’s Hospital) have demonstrated that most responding doctors agreed with this demand.

In conclusion, I would respectfully suggest that there is sufficient evidence to consider an investigation into the conduct of Professor Crockard in relation to his role as national director of MMC. In company with my many correspondents both within and outside the profession, I am concerned that his actions may have seriously damaged the good reputation of the profession, and eroded the trust that the public have in doctors.

Patricia Hewett says everyone supports MMC (see BBC news link below). This is an outright lie. For example, at a meeting at the Royal College of Physicians yesterday, they were worried the new MMC system was not going to produce any research doctors or clinical pharmacologists.

Not having clinical pharmacologists will be terrible. Prescribing errors will increase enourmously and there is a death rate through this each year. Clinical pharmacologists teach prescribing and maintain the standard.

I see the comments have more or less fizzled out on this thread, but I wanted to add one more.

A good friend of mine has just gone through exactly this process, she is graduating Medicine this summer (we hope), and lining up jobs for next year. She reviles this online system for much the same reason that Boris does; she is very intelligent (and fittingly got the maximum 45 marks for the academic part of her application), but was blighted by the ridiculous and impersonal online form, which is marked according to a mark scheme – getting 21 out of 40.

This is a ridiculously low score in her case, she has very extensive experience and a great deal she could put down, but was prevented from doing so as there was no box for i on the form, and no marks for it if there had been. She was also prevented from talking about her passion for medicine, how she wants to help, who she wants to help, and so on.

But most ridiclously of all is another thing Boris mentioned – she had nearly no ability to choose her speciality. She is very interested in Obstetrics and Gynacology, but is being forced into a Gastro-something-or-other instead. This is because she couldn’t apply for specific roles – and couldn’t explain why she was doing so if she could. In addition she can’t explain why she wants to work where she does (her husband cannot move, and so she now faces a very long commute!)

As such, she is being forced to work in a hospital far away, at a discipline she has neither interest nor special aptitude for. It defies all logic!

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